The Bronx, New York: Quality Job, Quality Care

Home health care workers often struggle with low pay and low-status, back-breaking jobs. But these home care aides are owners of their company, and that changes everything—for them and for their vulnerable patients.

Workers practicing blood pressure monitoring during their 5-week comprehensive training. The industry standard is two weeks.

New York's Cooperative Home Care Associates (CHCA) is one of the most successful worker-owned companies in the U.S. What's more, it thrives in a business that traditionally is scarred by near-sweatshop conditions, minimal job training and security, low wages, and few benefits.

CHCA is a fast-growing cooperative of 950 workers who tend to elderly and disabled patients in the Bronx and upper Manhattan. In recent years, the cooperative has been extending its formula to other cities and even to rural areas.

CHCA worker-owners have always believed that a quality job means quality care. They pay themselves above-average wages and guarantee each worker a minimum number of hours a week. The co-op offers comprehensive training, health and life insurance, career support — such as subsidies for college-level nursing courses — and 401(k) retirement contributions. All of this creates a core of workers who provide more professional care.

So does worker democracy. Workers and patients agree that the agency's model increases its responsiveness to the needs of both workers and patients. Workers say their quality of life is better than with other agencies, not just because their wages are higher, but because CHCA’s training program aims at creating something more like a corps of professionals than an assembly-line of low-wage, low-skill medicine dispensers.

Here’s how it works: Eighty percent of CHCA’s workers are also owners, meaning they each own a share in the company. A share costs $1,000, but each worker need only pay $50 up front, plus $3.65 out of her weekly paycheck, to cover the purchase. Each worker can buy only one share, however, and it can’t be transferred. As soon as she signs up, she’s entitled to all the rights of a full shareholder, which include electing eight of 13 members of the cooperative’s board. The board sets wages, benefits, bonuses, dividends, and retained earnings. In addition to being part of the decision-making and ownership structure, worker-owners get a share in CHCA’s profits. In most years, they each receive a dividend of between $200 and $800.

The worker-owner structure has helped CHCA evolve employment practices that minimize the disadvantages felt by new recruits, 70 percent of whom have been on public assistance. CHCA charges no fee for training and provides a stipend for new employees to purchase uniforms. Employees have the opportunity to move up into administrative and training positions within the cooperative, and CHCA encourages workers who want to become nurses to pursue training to do so.

The cooperative’s focus is on improving the status of home health care as an occupation, making it a viable, long-term decent living for the workers and their families. So the emphasis is on helping workers to stick with it rather than seek other occupations. For instance, CHCA has a tiered wage system so that workers move up as they acquire more skills and experience. It also clusters workers in five regions, which enables them to develop better and stronger relationships with their supervisors.

As a result of these policies, turnover is low — some workers have been with CHCA for as long as 18 years.

Another result is that the worker-owners have built a culture sufficiently rewarding to them that they have been willing to make sacrifices at times when it’s in their — and the cooperative’s—best interest. In one recent year, for example, when earnings were especially good, the board voted to reduce the dividend. Concerned that too few workers were contributing to their 401(k) retirement accounts, it decided to use part of the earnings to make a substantial contribution to each account and keep some of the rest as retained earnings. The result was a financial cushion for CHCA—and enough encouragement to boost workers’ 401(k) contribution rate to 95 percent.

CHCA has also developed a training program that’s more extensive and less hierarchical than other agencies’ and emphasizes people skills more heavily. All workers get the same comprehensive training, regardless of whether an individual spends most of her time doing catheter irrigations or preparing meals for clients, and are paid accordingly. New recruits get four to five weeks of training rather than the more typical two. Much of the additional time is devoted to 'soft' skills needed to work with clients living on their own, rather than just “hard” skills needed to provide technical services.

All of this reflects the worker/owners’ desire to create a model of care that better reflects the demands of the situation in which they operate. When workers sense a need or a deficiency in the care they’re providing, they have the power to make changes. CHCA’s training emphasizes soft skills, for example, because workers understood from experience that their patients, who often lead isolated lives, need conversation and companionship as much as they do medical attention.

Worker Democracy

CHCA is taking its worker ownership model on the road. Eight years ago, it set up the Paraprofessional Healthcare Institute (PHI), a non-profit that is bringing the cooperative’s model to 13 other states and helped launch successful cooperatives in Philadelphia and rural New Hampshire.

CHCA and PHI believe they can raise the status of home health care work. As the population ages and America’s 77 million baby boomers begin retiring, the low wages and low status of home health workers will improve, says CHCA president Michael Elsas. “The baby boomers are not going to want to go into nursing homes.”

CHCA has been actively exploring ways to expand its market. Five years ago, Rick Surpin, who founded the cooperative in 1985, left to start Independence Care Systems, a Medicaid-funded long-term care program for disabled people who want to live independently — a market other providers had mostly ignored. Independence contracts with CHCA to provide home health care workers to its clients, creating a new pool of business — a major reason its staff has nearly doubled over the past five years.

CHCA hopes to maintain its cooperative business model in spite of its rapid growth, but that may take some adjustments. The best response may be a stronger dose of what remains one of CHCA’s greatest strengths: worker democracy.

"Rather than having our meetings [in the cooperative’s headquarters on East 149th Street], we’ll have them in six locations around the Bronx," Elsas muses. A small move, perhaps, but yet another way to keep “ownership” close to the workers.

Eric Laursen is a New York-based independent journalist. He is currently writing a history of the Social Security debate.